Coursework and Final Examinations

MEDICAL CERTIFICATE/REPORT

(Coursework and Final Examinations)

To be completed by Medical Officer and submitted to the Head, Medical Unit, St Augustine Campus in accordance with University regulations (21) (ii) which states that in cases of illness the candidate shall present to the Campus Registrar a medical certificate as proof of illness, signed by the University Health Officer or by any other medical practitioner approved for this purpose by the University. The candidate shall send the medical certificate within seven days from the date of that part of the examination in which the performance of the candidate is affected.

PART A – TO BE COMPLETED BY STUDENT:

Surname______First Name______

Student ID#______Faculty______

Academic Year ______Semester I Semester II

Summer/Resit Level ______

Course-Work Mid-Term Final Exam General/Other

I,______, hereby authorize Dr./Mr./Ms.______

to provide the following information to the Student Medical Officer, The University of the West Indies and, if required to supply additional information to support my request for academic consideration for medical reasons. My personal information will be used for administrative and academic record-keeping, academic integrity purposes and the provision of services to students.

______

Signature Date (yy/mm/dd)

MEDICAL CERTIFICATES MUST BE SUBMITTED WITHIN SEVEN (7) DAYS FROM THE DATE OF EXAMINATION.

NAME OF STUDENT: ______

COURSE CODE (S): ______

______

SIGNATURE OF RECIPIENT: ______

(Health Services Unit)

DATE RECEIVED BY HEALTH SERVICES UNIT: ______

PART B – TO BE COMPLETED BY PHYSICIAN:

1. I hereby certify that I provided Health Care Services to the above named student on

______.

Insert date(s) student seen in your office

2. The student could not reasonably be expected to complete academic responsibilities

for the following reasons:

______

______

______

______

3. This is an acute / chronic problem for this student.

4. Date(s) during which student claims to have been affected by this problem:

______

5. Unable to complete academic responsibilities for:

24 hours 2 days

3 days 4 days

5 days Other (please indicate) ______

DATES: From______to ______

6. If the student is permitted to continue his/her course of study, is the medical

problem likely to recur and affect his/her studies again? Yes No

Reason:______

______

7. If the student is permitted to continue his/her course of study, are there any

accommodations, restrictions or special conditions that need to be followed?

Yes No

If yes, provide details:______

______

______

PHYSICIAN VERIFICATION

Name :(please print) ______Registration No.______

Signature: ______Telephone No.______

Stamp: ______